View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0420-0510
ICR Reference No:
201612-0420-002
Status:
Historical Active
Previous ICR Reference No:
201401-0420-004
Agency/Subagency:
PEACE
Agency Tracking No:
PC-1789
Title:
Peace Corps Health History Form
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
Yes
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
02/10/2017
Retrieve Notice of Action (NOA)
Date Received in OIRA:
12/20/2016
Terms of Clearance:
Peace Corps must submit an amended request to OMB to implement an electronic version of this form.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
02/29/2020
36 Months From Approved
03/31/2017
Responses
23,000
0
10,000
Time Burden (Hours)
17,250
0
7,500
Cost Burden (Dollars)
0
0
0
Abstract:
All Peace Corps Volunteer applicants must undergo a physical examination prior to service during the application process to ensure good health and be able to serve without undue disruption due to health problems.
Authorizing Statute(s):
US Code:
22 USC 2504(e)
Name of Law: Peace Corps Act
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
81 FR 39291
06/16/2016
30-day Notice:
Federal Register Citation:
Citation Date:
81 FR 63504
09/15/2016
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Health History Form (PC 1789)
PC-1789
Health History Form
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
23,000
10,000
0
13,000
0
0
Annual Time Burden (Hours)
17,250
7,500
0
9,750
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
This revised Health History Form which replaces the current Health History Form will result in most Applicants answering significantly fewer questions than they would with the current Health History Form. Applicants will gain access to the Health History Form via a secure online portal. The link to the portal will be sent to applicants via email. The Peace Corps anticipates that most Applicants will complete the Health History Form online and that only those few with no electronic access (expected to be no more than 10 Applicants a year) will submit a paper version.
Annual Cost to Federal Government:
$100,000
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Monique Harris 202 692-2167 mharris@peacecorps.gov
Common Form ICR:
Yes
Description/Changes for Common Form Usage:
Approved RCFs using this ICR
Agency/Sub Agency
RCF ID
RCF Title
RCF Status
IC Title
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
12/20/2016
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